Anti-Black discrimination in primary health care: a qualitative study exploring internalized racism in a Canadian context

OBJECTIVES

A growing body of evidence points to persistent health inequities within racialized minority communities, and the effects of racial discrimination on health outcomes and health care experiences. While much work has considered how anti-Black racism operates at the interpersonal and institutional levels, limited attention has focused on internalized racism and its consequences for health care. This study explores patients' attitudes towards anti-Black racism in a Canadian health care system, with a particular focus on internalized racism in primary health care.

DESIGN

This qualitative study employed purposive maximal variation and snowball sampling to recruit and interview self-identified Black persons aged 18 years and older who: (1) lived in Montréal during the COVID-19 pandemic, (2) could speak English or French, and (3) were registered with the Québec health insurance program. Adopting a phenomenological approach, in-depth interviews took place from October 2021 to July 2022. Following transcription, data were analyzed thematically.

RESULTS

Thirty-two participants were interviewed spanning an age range from 22 years to 79 years (mean: 42 years). Fifty-nine percent of the sample identified as women, 38% identified as men, and 3% identified as non-binary. Diversity was also reflected in terms of immigration experience, financial situation, and educational attainment. We identified three major themes that describe mechanisms through which internalized racism may manifest in health care to impact experiences: (1) the internalization of anti-Black racism by Black providers and patients, (2) the expression of anti-Black prejudice and discrimination by non-Black racialized minority providers, and (3) an insensitivity towards racial discrimination.

CONCLUSION

Our study suggests that multiple levels of racism, including internalized racism, must be addressed in efforts to promote health and health care equity among racialized minority groups, and particularly within Black communities.

Self-care interventions to assist family physicians with mental health care of older patients during the COVID-19 pandemic: Feasibility, acceptability, and outcomes of a pilot randomized controlled trial

BACKGROUND

The COVID-19 pandemic has required family physicians to rapidly address increasing mental health problems with limited resources. Vulnerable home-based seniors with chronic physical conditions and commonly undermanaged symptoms of anxiety and depression were recruited in this pilot study to compare two brief self-care intervention strategies for the management of symptoms of depression and/or anxiety.

METHODS

We conducted a pilot RCT to compare two tele-health strategies to address mental health symptoms either with 1) validated CBT self-care tools plus up to three telephone calls from a trained lay coach vs. 2) the CBT self-guided tools alone. The interventions were abbreviated from those previously trialed by our team, to enable their completion in 2 months. Objectives were to assess the feasibility of delivering the interventions during a pandemic (recruitment and retention); and assess the comparative acceptability of the interventions across the two groups (satisfaction and tool use); and estimate preliminary comparative effectiveness of the interventions on severity of depression and anxiety symptoms. Because we were interested in whether the interventions were acceptable to a wide range of older adults, no mental health screening for eligibility was performed.

RESULTS

90 eligible patients were randomized. 93% of study completers consulted the self-care tools and 84% of those in the coached arm received at least some coaching support. Satisfaction scores were high among participants in both groups. No difference in depression and anxiety outcomes between the coached and non-coached participants was observed, but coaching was found to have a significant effect on participants' use and perceived helpfulness of the tools.

CONCLUSION

Both interventions were feasible and acceptable to patients. Trained lay coaching increased patients' engagement with the tools. Self-care tools offer a low cost and acceptable remote activity that can be targeted to those with immediate needs. While effectiveness results were inconclusive, this may be due to the lack of eligibility screening for mental health symptoms, abbreviated toolkit, and fewer coaching sessions than those used in our previous effective interventions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT0460937.

Adaptation and outcomes of a lay-guided mental health self-care model: Results of six trials

OBJECTIVE

To synthesize results of six controlled trials of self-care interventions for depression and/or anxiety, focusing on five trials in which lay guidance was compared to self-directed use of the same self-care tools.

METHODS

The trials were conducted in Canada in different target populations. Self-care tools were adapted to each population. Guidance was provided in 3-15 calls over a period of 6-26 weeks. Depression and/or anxiety were assessed at follow-up (6-26 weeks). Pooled analyses used a meta-analytic approach. Engagement with the self-care tools was compared using the standardized difference or Cohen's d effect size.

RESULTS

In studies with homogeneous outcomes (three for depression, four for anxiety), the pooled effect sizes of guidance vs. self-directed use of the self-care tools were 0.36 (95% CI 0.10, 0.62, N = 235) for depression and 0.21 (95% CI -0.03, 0.44, N = 285) for anxiety. Guidance consistently led to greater engagement with the tools.

CONCLUSIONS

The intervention model is a potentially sustainable and accessible alternative to professionally guided self-care for people with mild-moderate depression. Factors which may have limited implementation success include: co-interventions, reduced number of guide calls (3 vs 6 or more), and delivery to dyads (patient-caregiver).

Integrating Health and Social Care for Community-Dwelling Older Adults: A Description of 16 Canadian Programs

This paper describes 16 Canadian programs designed to provide integrated primary care for older adults. Publicly available data were used to identify the "what" and the "how" of integration for each program. Most programs integrated with other healthcare or medical services (vs. social services). Mechanisms of integration varied; the most common mechanism was interprofessional teams. Only 25% of the programs formally engaged with autonomous physician-led primary care practices (where most Canadians receive their primary care). Findings suggest that integrated care is a priority across Canada but also highlight how far we have to go to achieve both vertical integration within the healthcare sector (primary, secondary and tertiary services) and horizontal integration across sectors (health and social).

Innovative Programs with Multi-Service Integration for Children and Youth with High Functional Health Needs

The integration of care services and providers across the health-social-community continuum has helped improve the lives of many children and youth living with complex health conditions. Using environmental scan data, 16 promising multi-service programs were selected and analyzed qualitatively through a deliberative conversation approach. Descriptive data of analyzed programs are presented, as well as the thematic analysis results. An important program strength is its clear founding principles and engagement of patients and families. However, the scale-up of these initiatives remains a challenge unless such programs can be better financed and supported.

Lack of Publicly Available Documentation Limits Spread of Integrated Care Innovations in Canada

As healthcare in Canada is provincially operated, the program innovations in one jurisdiction may not be readily known in other jurisdictions. We examine the availability of implementation-specific data for 30 innovative Canadian programs designed to integrate health and social services for patients with complex needs. Using publicly available data and key informant interviews, we were able to populate only ∼50% of our data collection tool (on average). Formal program evaluations were available for only ∼30% of programs. Multiple barriers exist to the compilation and verification of healthcare programs' implementation data across Canada, limiting cross-jurisdictional learning and making a comparison of programs challenging.

Inconsistent Governance Structures for Health and Social Services Limit Service Integration for Patients with Complex Care Needs

This paper describes how health and social services are governed and organized across Canada for two patient groups. Governance configurations and governance proximity between primary care and priority health and social services varied markedly between provinces. While the need for integrated service delivery has been made a clear priority during the COVID-19 pandemic, the potential of Canada's healthcare systems has not yet translated into coordinated and integrated care for health services, much less for health and social services. It is time to act on the policy recommendations from commissioned reports over the past two decades that focus on comprehensive, community-based care.

Toward Comprehensive Care Integration in Canada: Delphi Process Findings from Researchers, Clinicians, Patients and Decision Makers

Introduction

From a larger study examining policy and program information on how Canadian provinces integrate care services, this study aimed to create "priority lists" of 10-15 services that are "absolutely needed" for care integration.

Methodology

A diverse group of over 50 Canadian stakeholders participated in virtual consensus-building using the nominal group technique and a modified e-Delphi method to identify services that focused on two different groups: children and youth with high functional health needs and older adults in functional decline.

Results

Three lists - containing services, processes and infrastructure elements - emerged: one per tracer condition group and a consolidated list. The latter identified the following five services as top priority for primary care integration: mental health and addictions services; home care; transition between urgent-emergency-acute care; medication reconciliation in community pharmacies; and respite care. No single social service was a clear priority, but those that mitigate material deprivation emerged within the top 10.

Discussion

This humble pan-Canadian study shows that priority services in health and social services are neither well integrated nor connected to primary care. It also suggests that effective policy strategizing for primary care integration for those with complex care needs may require thinking beyond the logic of services - given their siloed organization.

Connecting Health and Social Services for Patients with Complex Care Needs: A Pan-Canadian Comparative Policy Research Program

Comprehensive primary healthcare for patients with complex care needs requires connections to other health services, social services and community supports. This descriptive comparative policy research program used publicly available documents and informant interviews to examine progress toward integrated comprehensive care through the lens of services needed by children and youth (0-25 years) and community-dwelling older adults (≥ 65 years) with high functional health needs. This article describes five projects. The following three findings emerged across all the projects: Canada indeed has multiple health systems; numerous integrated service delivery solutions are being trialled and most focus on medical services; and it is an ongoing challenge for ministries of health to engage physicians and physician associations in integration.

Have Primary Care Renewal Initiatives in Canada Increased Comprehensive Care for Patients with Complex Care Needs? Yes and No

The First Ministers Health Accords of 2001 through 2003 (Health Canada 2006) launched the renewal of primary care toward more comprehensive care delivery models. We scanned government websites in the 10 Canadian provinces to assess how comprehensive and integrated renewal models were for health and social services in 2018. More comprehensive primary care delivery models were the norm in five out of 10 provinces. The policy approaches were: (1) expanding traditional family practice; (2) creating primary care networks; and (3) increasing the number of community health centres, which provide the broadest range of health and social care. Integration initiatives were limited to medical services. Additional financial and policy investments will be required to meet the comprehensive needs of patients with complex health and social needs at a system level.

Patient Partners Respond to High-Level Findings on the Connectedness of Health and Social Services across Canada

This short article captures input from patient partners on the dimensions of the research program that most resonated with them. They are passionate about wanting to see a better connection between health and social services, and they are also willing to be involved as advisors for policy directions in the same way as their involvement has become the norm in any patient-oriented research.

Telephone outreach by volunteer navigators: a theory-based evaluation of an intervention to improve access to appropriate primary care

BACKGROUND

A pilot intervention in a participatory research programme in Québec, Canada, used telephone outreach by volunteer patient navigators to help unattached persons from deprived neighbourhoods attach successfully to a family doctor newly-assigned to them from a centralized waiting list. According to our theory-based program logic model we evaluated the extent to which the volunteer navigator outreach helped patients reach and engage with their newly-assigned primary care team, have a positive healthcare experience, develop an enduring doctor-patient relationship, and reduce forgone care and emergency room use.

METHOD

For the mixed-method evaluation, indicators were developed for all domains in the logic model and measured in a telephone-administered patient survey at baseline and three months later to determine if there was a significant difference. Interviews with a subsample of 13 survey respondents explored the mechanisms and nuances of intended effects.

RESULTS

Five active volunteers provided the service to 108 persons, of whom 60 agreed to participate in the evaluation. All surveyed participants attended the first visit, where 90% attached successfully to the new doctor. Indicators of abilities to access healthcare increased statistically significantly as did ability to explain health needs to professionals. The telephone outreach predisposed patients to have a positive first visit and have trust in their new care team, establishing a basis for an enduring relationship. Patient-reported access difficulties, forgone care and use of hospital emergency rooms decreased dramatically after patients attached to their new doctors.

CONCLUSIONS

As per the logic model, telephone outreach by volunteer navigators significantly increased patients' abilities to seek, reach and engage with care and helped them attach successfully to newly-assigned family doctors. This light-touch intervention may have promise to achieve of the intended policy goals for the centralized waiting list to increase population access to appropriate primary care and reduce forgone care.

Development of an individual index of social vulnerability that predicts negative healthcare events: a proposed tool to address healthcare equity in primary care research and practice

PURPOSE

Socially disadvantaged patients may lack self-efficacy to navigate a complex health system making them vulnerable to healthcare inequity. We aimed to develop an Index of social vulnerability that predicts increased risk of negative healthcare events (e.g. emergency hospitalization), independent of chronic disease burden. The analysis illustrates the conceptual and practical steps leading to the development of a pragmatic Index of social vulnerability to limited healthcare self-efficacy.

METHODS

Using data from a 3-year cohort of 2507 adult primary care patients in Québec (Canada), we applied two complementary structural equation modelling approaches-Partial Least Squares Path Modelling (PLS-PM) and Multiple indicators and Multiple Causes (MIMIC) modelling-to identify a minimal set of social characteristics that could be summed into an Index related to limited healthcare self-efficacy. We then used logistic regression to determine if the Index predicted: hospital emergency department use; hospital admissions; unmet need for care, and others. We privileged parsimony over explanatory capacity in our analytic decisions to make the Index pragmatic for epidemiologic and clinical use.

RESULTS

The Individual Social Vulnerability Index is the weighted sum of five indicators: two indicators of social support; educational achievement; financial status; limited language proficiency. The Index predicts increased likelihood of all negative healthcare outcomes except unmet need, with a clear threshold at Index ≥ 2. The effect is independent of chronic disease burden.

CONCLUSION

When social deficits outweigh social assets by two or more (Index ≥ 2), there is an increased risk of negative healthcare events beyond the risk attributable to poor health. The Index is a pragmatic tool to identify a minority of patients who will require additional support to receive equitable healthcare.

Patients Living with Social Vulnerabilities Experience Reduced Access at Team-Based Primary Healthcare Clinics

Objective

This study aims to explore differences in access to care as experienced by patients registered in team-based primary healthcare clinics according to their social vulnerability profile.

Method

A total of 1,562 patients from four team-based primary healthcare clinics completed an e-survey conducted between June and November 2021. The social vulnerability index was used to compare the experiences.

Results

Patients with low vulnerability consulted at emergency rooms three times more often because their family physician was not available (p = 0.006) than patients with no vulnerability. Lack of continuity was reported two times more often by patients with low vulnerability related to team members not knowing their recent medical history (p = 0.006) and by patients with high vulnerability related to no one being in charge of their file (p = 0.023). Both vulnerable groups reported receiving contradictory information more often than patients with no vulnerability.

Conclusion

Patients with high vulnerability experienced more access difficulties related to continuity, interprofessional collaboration and communication with providers.

Perceived Access and Appropriateness: Comparison of Teaching and Resident Family Physicians' Patients

BACKGROUND AND PURPOSE

Teaching clinics aim to provide patients with care that is comprehensive, high quality, and timely. Since resident presence at the clinic is irregular, timely access to care and continuity remain challenging. The two main objectives of our study were to compare the experience of timely access by patients of family residents vs staff and to determine if there was a difference between resident and staff patients in reported appropriateness and patient-centeredness of the visit.

METHODS

This cross-sectional survey study was carried out in nine family medicine teaching clinics part of University of Montreal and McGill University Family Medicine Networks. Patients self-administered two anonymous questionnaires, before and after their consultation.

RESULTS

We collected 1,979 preconsultation questionnaires. Teaching physician (staff) patients rated the usual wait time for an appointment as very good or excellent more frequently than resident patients (46% vs 35 %; P=.001). One out of five reported consulting another clinic in the last 12 months. Resident patients consulted elsewhere more often. In postconsultation questionnaires staff patients rated their visit experience better than resident physician patients and patients of second-year residents better than first-year residents.

CONCLUSION

Although patients generally have a positive perception of access to care and adequacy of the consultations meet their needs, staff also face the challenge of providing better access to their patients. Finally, we found the patients' perceived visit-based patient centeredness was higher for visits of second-year than first-year resident physicians, supporting the impact of training efforts toward patient-centered best practices.

Telemedicine perceptions and experiences of socially vulnerable households during the early stages of the COVID-19 pandemic: a qualitative study

BACKGROUND

Early in the COVID-19 pandemic, efforts to decrease risk of viral transmission triggered an abrupt shift from ambulatory health care delivery toward telemedicine. In this study, we explore the perceptions and experiences of telemedicine among socially vulnerable households and suggest strategies to increase equity in telemedicine access.

METHODS

Conducted between August 2020 and February 2021, this exploratory qualitative study involved in-depth interviews with members of socially vulnerable households needing health care. Participants were recruited from a food bank and primary care practice in Montréal. Digitally recorded telephone interviews focused on experiences and perceptions related to telemedicine access and use. In our thematic analysis, we employed the framework method to facilitate comparison, and the identification of patterns and themes.

RESULTS

Twenty-nine participants were interviewed, 48% of whom presented as women. Almost all sought health care in the early stages of the pandemic, 69% of which was received via telemedicine. Four themes emerged from the analysis: delays in seeking health care owing to competing priorities and perceptions that COVID-19-related health care took precedence; challenges with appointment booking and logistics given complex online systems, administrative inefficiencies, long wait times and missed calls; issues around quality and continuity of care; and conditional acceptance of telemedicine for certain health problems, and in exceptional circumstances.

INTERPRETATION

Early in the pandemic, participants report telemedicine delivery did not accommodate the diverse needs and capacities of socially vulnerable populations. Patient education, logistical support and care delivery by a trusted provider are suggested solutions, in addition to policies supporting digital equity and quality standards to promote telemedicine access and appropriate use.

Improved access to and continuity of primary care after attachment to a family physician: longitudinal cohort study on centralized waiting lists for unattached patients in Quebec, Canada

Background

Having a regular family physician is associated with many benefits. Formal attachment – an administrative patient-family physician agreement – is a popular feature in primary care, intended to improve access to and continuity of care with a family physician. However, little evidence exists about its effectiveness. In Quebec, Canada, where over 20% of the population is unattached, centralized waiting lists help attach patients. This provides a unique opportunity to observe the influence of attachment in previously unattached patients. The aim was to evaluate changes in access to and continuity of primary care associated with attachment to a family physician through Quebec’s centralized waiting lists for unattached patients.

Methods

We conducted an observational longitudinal population cohort study, using medical services billing data from public health insurance in the province of Québec, Canada. We included patients attached through centralized waiting lists for unattached patients between 2012 and 2014 (n = 410,140). Our study was informed by Aday and Andersen’s framework for the study of access to health services. We compared outcomes during four 12-month periods: two periods before and two periods after attachment, with T0–2 years as the reference period. Outcome measures were number of primary care visits and Bice-Boxerman Concentration of Care Index at the physician and practice level (for patients with ≥2 visits in a given period). We included age, sex, region remoteness, medical vulnerability, and Charlson Comorbidity Index as covariates in regression models fitted with generalized estimating equations.

Results

The number of primary care visits increased by 103% in the first post attachment year and 29% in the second year (p < 0.001). The odds of having all primary care visits concentrated with a single physician increased by 53% in the first year and 22% (p < 0.001) in the second year after attachment. At the practice level, the odds of perfect concentration of care increased by 19% (p < 0.001) and 15% (p < 0.001) respectively, in first and second year after attachment.

Conclusion

Our results show an increase in patients’ number of primary care visits and concentration of care at the family physician and practice level after attachment to a family physician. This suggests that attachment may help improve access to and continuity of primary care.

Complex skills are required for new primary health care researchers: a training program responds

BACKGROUND

Current dimensions of the primary health care research (PHC) context, including the need for contextualized research methods to address complex questions, and the co-creation of knowledge through partnerships with stakeholders - require PHC researchers to have a comprehensive set of skills for engaging effectively in high impact research.

MAIN BODY

In 2002 we developed a unique program to respond to these needs - Transdisciplinary Understanding and Training on Research - Primary Health Care (TUTOR-PHC). The program's goals are to train a cadre of PHC researchers, clinicians, and decision makers in interdisciplinary research to aid them in tackling current and future challenges in PHC and in leading collaborative interdisciplinary research teams. Seven essential educational approaches employed by TUTOR-PHC are described, as well as the principles underlying the curriculum. This program is unique because of its pan-Canadian nature, longevity, and the multiplicity of disciplines represented. Program evaluation results indicate: 1) overall program experiences are very positive; 2) TUTOR-PHC increases trainee interdisciplinary research understanding and activity; and 3) this training assists in developing their interdisciplinary research careers. Taken together, the structure of the program, its content, educational approaches, and principles, represent a complex whole. This complexity parallels that of the PHC research context - a context that requires researchers who are able to respond to multiple challenges.

CONCLUSION

We present this description of ways to teach and learn the advanced complex skills necessary for successful PHC researchers with a view to supporting the potential uptake of program components in other settings.

Revising the advanced access model pillars: a multimethod study

BACKGROUND

The advanced access model was developed 20 years ago and has been implemented in several countries. We aimed to revise and operationalize the pillars and subpillars of the advanced access model based on its contemporary practice by professionals in primary health care.

METHODS

This multimethod sequential study was informed by a literature review and an expert panel of provincial and local decision-makers, primary health care clinic members (family physicians, nurses and administrative staff), patients and researchers from the province of Quebec. Throughout the consultation process, participants were asked to develop a common vision of the pillars and subpillars that make up the advanced access model and to react to suggested definitions or content.

RESULTS

The revised advanced access model is defined by 5 pillars, of which 2 were updated from the original model ("Appointment system" and "Interprofessional practice"), 1 was merged with a revised pillar ("Develop contingency plans" with "Planning of needs and supply") and 1 underwent major transformations ("Backlog reduction" to "Continuous adjustment"). A new pillar concerning communication emerged from the consultation process. Subsequent steps for operationalizing definitions of subpillars confirmed the nature of the revised advanced access pillars and stabilized their content.

INTERPRETATION

The overall consultation process resulted in a revised contemporary advanced access model, with strong consensus among participating experts. The revised model will be used to develop a reflective tool for primary health care professionals to evaluate their advanced access practice.

Use of a risk communication survey to prioritize family-valued outcomes and communication preferences for children undergoing outpatient surgical procedures

BACKGROUND

Effective shared decision-making in pediatric surgery requires clarity regarding which surgical outcomes are most important to patients and their families, and how they prefer to receive the information. Despite how essential this is for effective risk communication, little is known about the communication needs and preferences of patients and their families in elective pediatric surgery.

METHODS

We administered a mailed and online cross-sectional survey in English and French to 548 families before or after surgery for hernia/hydrocele repair or tonsillectomy/adenoidectomy between July 2019 and February 2021. The survey consisted of 22 questions eliciting most valued patient-reported outcomes (PROs) across 4 domains: health-related quality of life (5), functional status (5), symptoms and symptom burden (5), health behaviours and patient experience (7), as well as overall impressions (3), surgical risks (5), communication preferences (4), and demographic questions (16).

RESULTS

The survey was completed by 368 patient families (60 preoperative, 308 postoperative, response rate 67.2%). Most respondents (72%) indicated a significant desire to be informed on all listed PROs alongside surgical complications, and highly valued all functional and quality of life outcomes (92.9% & 89.8%, respectively). Preoperatively, patient families preferred to receive information in the form of pamphlets and websites, whereas postoperatively they preferred direct communication.

CONCLUSION

Families value functional and quality of life PROs as much as clinical outcomes, and increasingly seek more contemporary (electronic) means of risk communication than we currently offer. This data will inform the development of mobile tools for personalized communication in pediatric surgery.

Comparing the Attainment of the Patient's Medical Home Model across Regions in Three Canadian Provinces: A Cross-Sectional Study

Background:

The aim of this work was to show the feasibility of providing a comprehensive portrait of regional primary care performance.

Methods:

The TRANSFORMATION study used a mixed-methods concurrent study design where we analyzed survey data and case studies. Data were collected in British Columbia, Ontario and Nova Scotia. Patient's Medical Home (PMH) pillar scores were created by calculating mean clinic-level scores across regions. Scores and qualitative themes were compared.

Results:

Participation included 86 practices (n = 1,929 patients; n = 117 clinicians). Regions had differential attainment towards PMH orientation with respect to infrastructure; community adaptiveness and accountability; and patient and family partnered care. The lowest PMH attainment for all regions were observed in connected care; accessible care; measurement, continuous quality improvement and research; and training, education and continuing professional development.

Conclusions:

Comprehensive performance reporting that draws on multiple data sources in primary care is possible. Regional portraits highlighting many of the key pillars of a PMH approach to primary care show that despite differences in policy contexts, achieving a PMH remains elusive.

Improving primary health care through partnerships: Key insights from a cross-case analysis of multi-stakeholder partnerships in two Canadian provinces

BACKGROUND AND AIMS

Multi-stakeholder partnerships offer strategic advantages in addressing multi-faceted issues in complex, fast-paced, and rapidly-evolving community health contexts. Synergistic partnerships mobilize partners' complementary financial and nonfinancial resources, resulting in improved outcomes beyond that achievable through individual efforts. Our objectives were to explore the manifestations of synergy in partnerships involving stakeholders from different organizations with an interest in implementing organizational solutions that enhance access to primary health care (PHC) for vulnerable populations, and to describe structures and processes that facilitated the work of these partnerships.

METHODS

This was a longitudinal case study in two Canadian provinces of two collaborative partnerships involving decision makers, academic representatives, clinicians, health system administrators, patient partners, and representatives of health and social service organizations providing services to vulnerable populations. Document review, nonparticipant observation of partnerships' meetings (n = 14) and semi-structured in-depth interviews (n = 16) were conducted between 2016 and 2018. Data analysis involved a cross-case synthesis to compare the cases and framework analysis to identify prominent themes.

RESULTS

Four major themes emerged from the data. Partnership synergy manifested itself in the following: (a) the integration of resources, (b) partnership atmosphere, (c) perceived stakeholder benefits, and (d) capacity for adaptation to context. Synergy developed before the intended PHC access outcomes could be assessed and acted both as a dynamic indicator of the health of the partnership and a source of energy fuelling partnership improvement and vitality. Synergistic action among multiple stakeholders was achieved through enabling processes at interpersonal, operational, and system levels.

CONCLUSIONS

The partnership synergy framework is useful in assessing the intermediate outcomes of ongoing partnerships when it is too early to evaluate the achievement of long-term intended outcomes. Enabling processes require attention as part of routine partnership assessment.

Development of a self-reported reflective tool on advanced access to support primary healthcare providers: study protocol of a mixed-method research design using an e-Delphi survey

INTRODUCTION

Timely access is one of the cornerstones of strong primary healthcare (PHC). New models to increase timely access have emerged across the world, including advanced access (AA). Recently in Quebec, Canada, the AA model has spread widely across the province. The model has largely been implemented by PHC professionals with important variations; however, a tool to assess their practice improvement within AA is lacking. The general objective of this study is to develop a self-reported online reflective tool that will guide PHC professionals' reflection on their individual AA practice and formulation of recommendations for improvement. Specific objectives are: (1) operationalisation of the pillars and subpillars of AA; (2) development of a self-reported questionnaire; and (3) evaluation of the psychometrics.

METHODS AND ANALYSIS

The pillars composing Murray's model of AA will first be reviewed in collaboration with PHC professional and stakeholders, patients and researchers in a face-to-face meeting, with the goal to establish consensus on the pillars and subpillars of AA. Leading from these definitions, items will be identified for evaluation through an e-Delphi consultation. Three rounds are planned in 2020-2021 with a group of 20-25 experts. A repository of recommendations on how to improve one's AA practice will be populated based on the literature and enriched by our experts throughout the consultation. Median and measures of dispersions will be used to evaluate agreement. The resulting tool will then be evaluated by PHC professionals for psychometrics in 2021-2022.

ETHICS AND DISSEMINATION

The Centre Intégré de Santé et de Services Sociaux de la Montérégie-Centre Scientific Research Committee approved the protocol, and the Research Ethics Board provided ethics approval (2020-441, CP 980475). Dissemination plan is a mix of community diffusion through and for our partners and to the scientific community including peer-reviewed publications and conference presentations.

Improving access to primary health care: a cross-case comparison based on an a priori program theory

Background

Inequitable access to primary health care (PHC) remains a problem for most western countries. Failure to scale up effective interventions has been due, in part, to a failure to share the logic and essential elements of successful programs. The aim of this paper is to describe what we learned about improving access to PHC for vulnerable groups across multiple sites through use of a common theory-based program logic model and a common evaluation approach. This was the IMPACT initiative.

Methods

IMPACT’s evaluation used a mixed methods design with longitudinal (pre and post) analysis of six interventions. The analysis for this paper included four of the six sites that met study criteria. These sites were located in Canada (Alberta, Quebec and Ontario) and Australia (New South Wales). Using the overarching logic model, unexpected findings were reviewed, and alternative explanations were considered to understand how the mechanisms of each intervention may have contributed to results.

Results

Each site addressed their local access problem with different strategies and from different starting points. All sites observed changes in patient abilities to access PHC and provider access capabilities. The combination of intended and observed consequences for consumers and providers was different at each site, but all sites achieved change in both consumer ability and provider capability, even in interventions where there was no activity targeting provider behaviors.

Discussion

The model helped to identify, explore and synthesize intended and unintended consequences of four interventions that appeared to have more differences than similarities. Similar outcomes for different interventions and multiple impacts of each intervention on abilities were observed, implying complex causal pathways.

Conclusions

All the interventions were a low-cost incremental attempt to address unmet health care needs of vulnerable populations. Change is possible; sustaining change may be more challenging. Access to PHC requires attention to both patient abilities and provider characteristics. The logic model proved to be a valuable heuristic tool for defining the objectives of the interventions, evaluating their impacts, and learning from the comparison of ‘cases’.

Expectations and needs of socially vulnerable patients for navigational support of primary health care services

BACKGROUND

Primary healthcare is the main entry to the health care system for most of the population. In 2008, it was estimated that about 26% of the population in Quebec (Canada) did not have a regular family physician. In early 2017, about 10 years after the introduction of a centralized waiting list for patients without a family physician, Québec had 25% of its population without a family physician and nearly 33% of these or 540,000, many of whom were socially vulnerable (SV), remained registered on the list. SV patients often have more health problems. They also face access inequities or may lack the skills needed to navigate a constantly evolving and complex healthcare system. Navigation interventions show promise for improving access to primary health care for SV patients. This study aimed to describe and understand the expectations and needs of SV patients.

METHODS

A descriptive qualitative study rooted in a participatory study on navigation interventions implemented in Montérégie (Quebec) addressed to SV patients. Semi-structured individual face-to-face and telephone interviews were conducted with patients recruited in three primary health care clinics, some of whom received the navigation intervention. A thematic analysis was performed using NVivo 11 software.

RESULTS

Sixteen patients living in socially deprived contexts agreed to participate in this qualitative study. Three main expectations and needs of patients for navigation interventions were identified: communication expectations (support to understand providers and to be understood by them, discuss about medical visit, and bridge the communication cap between patients and PHC providers); relational expectations regarding emotional or psychosocial support; and pragmatic expectations (information on available resources, information about the clinic, and physical support to navigate the health care system).

CONCLUSIONS

Our study contributes to the literature by identifying expectations and needs specified to SV patients accessing primary health care services, that relate to navigation interventions. This information can be used by decision makers for navigation interventions design and inform health care organizational policies.

Activating Partnership Assets to Produce Synergy in Primary Health Care: A Mixed Methods Study

Partnerships are an important mechanism to tackle complex problems that extend beyond traditional organizational divides. Partnerships are widely endorsed, but there is a need to strengthen the evidence base relating to claims of their effectiveness. This article presents findings from a mixed methods study conducted with the aim of understanding partnership processes and how various partnership factors contribute to partnership effectiveness. The study involved five multi-stakeholder partnerships in Canada and Australia working towards improving accessibility to primary health care for vulnerable populations. Qualitative data were collected through the observation of 14 partnership meetings and individual semi-structured interviews (n = 16) and informed the adaptation of an existing Partnership Self-Assessment Tool. The instrument was administered to five partnerships (n = 54). The results highlight partnership complexity and the dynamic and contingent nature of partnership processes. Synergistic action among multiple stakeholders was achieved through enabling processes at the interpersonal, operational and system levels. Synergy was associated with partnership leadership, administration and management, decision-making, the ability of partnerships to optimize the involvement of partners and the sufficiency of non-financial resources. The Partnership Synergy framework was useful in assessing the intermediate outcomes of ongoing partnerships when it was too early to assess the achievement of long-term intended outcomes.

Telehealth in Primary Healthcare: A Portrait of its Rapid Implementation during the COVID-19 Pandemic

OBJECTIVE

This study documents the adoption of telehealth by various types of primary healthcare (PHC) providers working in teaching PHC clinics in Quebec during the COVID-19 pandemic. It also identifies the perceived advantages and disadvantages of telehealth.

METHOD

A cross-sectional study was conducted between May and August 2020. The e-survey was completed by 48/50 teaching primary care clinics representing 603/1,357 (44%) PHC providers.

RESULTS

Telephone use increased the most, becoming the principal virtual modality of consultation, during the pandemic. Video consultations increased, with variations by type of PHC provider: between 2% and 16% reported using it "sometimes." The main perceived advantages of telehealth were minimizing the patient's need to travel, improved efficiency and reduction in infection transmission risk. The main disadvantages were the lack of physical exam and difficulties connecting with some patients.

CONCLUSION

The variation in telehealth adoption by type of PHC provider may inform strategies to maximize the potential of telehealth and help create guidelines for its use in more normal times.

Measuring partnership synergy and functioning: Multi-stakeholder collaboration in primary health care

In primary health care, multi-stakeholder partnerships between clinicians, policy makers, academic representatives and other stakeholders to improve service delivery are becoming more common. Literature on processes and approaches that enhance partnership effectiveness is growing. However, evidence on the performance of the measures of partnership functioning and the achievement of desired outcomes is still limited, due to the field's definitional ambiguity and the challenges inherent in measuring complex and evolving collaborative processes. Reliable measures are needed for external or self-assessment of partnership functioning, as intermediate steps in the achievement of desired outcomes. We adapted the Partnership Self-Assessment Tool (PSAT) and distributed it to multiple stakeholders within five partnerships in Canada and Australia. The instrument contained a number of partnership functioning sub-scales. New sub-scales were developed for the domains of communication and external environment. Partnership synergy was assessed using modified Partnership Synergy Processes and Partnership Synergy Outcomes sub-scales, and a combined Partnership Synergy scale. Ranking by partnership scores was compared with independent ranks based on a qualitative evaluation of the partnerships' development. 55 (90%) questionnaires were returned. Our results indicate that the instrument was capable of discriminating between different levels of dimensions of partnership functioning and partnership synergy even in a limited sample. The sub-scales were sufficiently reliable to have the capacity to discriminate between individuals, and between partnerships. There was negligible difference in the correlations between different partnership functioning dimensions and Partnership Synergy sub-scales. The Communication and External Environment sub-scales did not perform well metrically. The adapted partnership assessment tool is suitable for assessing the achievement of partnership synergy and specific indicators of partnership functioning. Further development of Communication and External Environment sub-scales is warranted. The instrument could be applied to assess internal partnership performance on key indicators across settings, in order to determine if the collaborative process is working well.

Nurse staffing practices and adverse events in acute care hospitals: The research protocol of a multisite patient-level longitudinal study

Aims

We describe an innovative research protocol to: (a) examine patient‐level longitudinal associations between nurse staffing practices and the risk of adverse events in acute care hospitals and; (b) determine possible thresholds for safe nurse staffing.

Design

A dynamic cohort of adult medical, surgical and intensive care unit patients admitted to 16 hospitals in Quebec (Canada) between January 2015–December 2019.

Methods

Patients in the cohort will be followed from admission until 30‐day postdischarge to assess exposure to selected nurse staffing practices in relation to the subsequent occurrence of adverse events. Five staffing practices will be measured for each shift of an hospitalization episode, using electronic payroll data, with the following time‐varying indicators: (a) nursing worked hours per patient; (b) skill mix; (c) overtime use; (d) education mix and; and (e) experience. Four high‐impact adverse events, presumably associated with nurse staffing practices, will be measured from electronic health record data retrieved at the participating sites: (a) failure‐to‐rescue; (b) in‐hospital falls; (c) hospital‐acquired pneumonia and; and (d) venous thromboembolism. To examine the associations between the selected nurse staffing exposures and the risk of each adverse event, separate multivariable Cox proportional hazards frailty regression models will be fitted, while adjusting for patient, nursing unit and hospital characteristics, and for clustering. To assess for possible staffing thresholds, flexible non‐linear spline functions will be fitted. Funding for the study began in October 2019 and research ethics/institutional approval was granted in February 2020.

Discussion

To our knowledge, this study is the first multisite patient‐level longitudinal investigation of the associations between common nurse staffing practices and the risk of adverse events. It is hoped that our results will assist hospital managers in making the most effective use of the scarce nursing resources and in identifying staffing practices that minimize the occurrence of adverse events.

Does healthcare inequity reflect variations in peoples' abilities to access healthcare? Results from a multi-jurisdictional interventional study in two high-income countries

Background

Primary healthcare services must respond to the healthcare-seeking needs of persons with a wide range of personal and social characteristics. In this study, examined whether socially vulnerable persons exhibit lower abilities to access healthcare. First, we examined how personal and social characteristics are associated with the abilities to access healthcare described in the patient-centered accessibility framework and with the likelihood of reporting problematic access. We then examined whether higher abilities to access healthcare are protective against problematic access. Finally, we explored whether social vulnerabilities predict problematic access after accounting for abilities to access healthcare.

Methods

This is an exploratory analysis of pooled data collected in the Innovative Models Promoting Access-To-Care Transformation (IMPACT) study, a Canadian-Australian research program that aimed to improve access to primary healthcare for vulnerable populations. This specific analysis is based on 284 participants in four study regions who completed a baseline access survey. Hierarchical linear regression models were used to explore the effects of personal or social characteristics on the abilities to access care; logistic regression models, to determine the increased or decreased likelihood of problematic access.

Results

The likelihood of problematic access varies by personal and social characteristics. Those reporting at least two social vulnerabilities are more likely to experience all indicators of problematic access except hospitalizations. Perceived financial status and accumulated vulnerabilities were also associated with lower abilities to access care. Higher scores on abilities to access healthcare are protective against most indicators of problematic access except hospitalizations. Logistic regression models showed that ability to access is more predictive of problematic access than social vulnerability.

Conclusions

We showed that those at higher risk of social vulnerability are more likely to report problematic access and also have low scores on ability to seek, reach, pay, and engage with healthcare. Equity-oriented healthcare interventions should pay particular attention to enhancing people’s abilities to access care in addition to modifying organizational processes and structures that reinforce social systems of discrimination or exclusion.

Predictors of patient satisfaction and outpatient health services in China: evidence from the WHO SAGE survey

BACKGROUND

Patient satisfaction is an essential indicator in medical practise and research. To monitor the health and well-being of adult populations and the ageing process, the World Health Organization (WHO) has initiated the Study on Global AGEing and Adult Health (SAGE), compiling longitudinal information in six countries including China as one major data source.

OBJECTIVE

The objective of this study was to identify potential predictors for patient satisfaction based on the 2007-10 WHO SAGE China survey.

METHODS

Data were analysed using random forests (RFs) and ordinal logistic regression models based on 5774 responses to predict overall patient satisfaction on their most recent outpatient health services visit over the last 12 months. Potential predictor variables included access to care, costs of care, quality of care, socio-demographic and health care characteristics and health service features. Increase of the mean-squared error (incMSE) due to variable removal was used to assess relative importance of the model variables for accurately predicting patient satisfaction.

RESULTS

The survey data suggest low frequency of dissatisfaction with outpatient services in China (1.8%). Self-reported treatment outcome of the respective visit of a care facility demonstrated to be the strongest predictor for patient satisfaction (incMSE +15%), followed by patient-rated communication (incMSE +2.0%), and then income, waiting time, residency and patient age. Individual patient satisfaction in the survey population was predicted with 74% accuracy using either logistic regression or RF.

CONCLUSIONS

Patients' perceived outcomes of health care visits and patient communication with health care professionals are the most important variables associated with patient satisfaction in outpatient health services settings in China.

Evaluation of the implementation and associated effects of advanced access in university family medicine groups: a study protocol

BACKGROUND

Timely access in primary health care is one of the key issues facing health systems. Among many interventions developed around the world, advanced access is the most highly recommended intervention designed specifically to improve timely access in primary care settings. Based on greater accessibility linked with patients' relational continuity and informational continuity with a primary care professional or team, this organizational model aims to ensure that patients obtain access to healthcare services at a time and date convenient for them when needed regardless of urgency of demand. Its implementation requires a major organizational change based on reorganizing the practices of all the administrative staff and health professionals. In recent years, advanced access has largely been implemented in primary care organizations. However, despite its wide dissemination, we observe considerable variation in the implementation of the five guiding principles of this model across organizations, as well as among professionals working within the same organization. The main objective of this study is to assess the variation in the implementation of the five guiding principles of advanced access in teaching primary healthcare clinics across Quebec and to better understand the influence of the contextual factors on this variation and on outcomes.

METHODS

This study will be based on an explanatory sequential design that includes 1) a quantitative survey conducted in 47 teaching primary healthcare clinics, and 2) a multiple case study using mixed data, contrasted cases (n = 4), representing various implementation profiles and geographical contexts. For each case, semi-structured interviews and focus group will be conducted with professionals and patients. Impact analyses will also be conducted in the four selected clinics using data retrieved from the electronic medical records.

DISCUSSION

This study is important in social and political context marked by accessibility issues to primary care services. This research is highly relevant in a context of massive media coverage on timely access to primary healthcare and a large-scale implementation of advanced access across Quebec. This study will likely generate useful lessons and support evidence-based practices to refine and adapt the advanced access model to ensure successful implementation in various clinical contexts facing different challenges.

Multimorbidity, polypharmacy and primary prevention in community-dwelling adults in Quebec: a cross-sectional study

BACKGROUND

Polypharmacy carries the risk of adverse events, especially in people with multimorbidity.

OBJECTIVE

To investigate the prevalence of polypharmacy in community-dwelling adults, the association of multimorbidity with polypharmacy and the use of medications for primary prevention.

METHODS

Cross-sectional analysis of the follow-up data from the Program of Research on the Evolution of a Cohort Investigating Health System Effects (PRECISE) in Quebec, Canada. Multimorbidity was defined as the presence of three or more chronic diseases and polypharmacy as self-reported concurrent use of five or more medications. Primary prevention was conceptualized as the use of statin or low-dose antiplatelets without a reported diagnostic of cardiovascular disease.

RESULTS

Mean age 56.7 ± 11.6, 62.5% female, 30.3% had multimorbidity, 31.9% had polypharmacy (n = 971). The most common drugs used were statins, renin-angiotensin system inhibitors and psychotropics. Compared to participants without any chronic disease, the adjusted odds ratios (ORs) for having polypharmacy were 2.78 [95% confidence interval (CI): 1.23-6.28] in those with one chronic disease, 8.88 (95% CI: 4.06-19.20) in those with two chronic diseases and 25.31 (95% CI: 11.77-54.41) in those with three or more chronic diseases, P < 0.001. In participants without history of cardiovascular diseases, 16.2% were using antiplatelets and 28.5% were using statins. Multimorbidity was associated with increased likelihood of using antiplatelets (adjusted OR: 2.98, 95% CI: 1.98-4.48, P < 0.001) and statins (adjusted OR: 3.76, 95% CI: 2.63-5.37, P < 0.001) for primary prevention.

CONCLUSION

There was a high prevalence of polypharmacy in community-dwelling adults in Quebec and a strong association with multimorbidity. The use of medications for primary prevention may contribute to polypharmacy and raise questions about safety.

Improving access to primary healthcare for vulnerable populations in Australia and Canada: protocol for a mixed-method evaluation of six complex interventions

INTRODUCTION

Access to primary healthcare (PHC) has a fundamental influence on health outcomes, particularly for members of vulnerable populations. Innovative Models Promoting Access-to-Care Transformation (IMPACT) is a 5-year research programme built on community-academic partnerships. IMPACT aims to design, implement and evaluate organisational innovations to improve access to appropriate PHC for vulnerable populations. Six Local Innovation Partnerships (LIPs) in three Australian states (New South Wales, Victoria and South Australia) and three Canadian provinces (Ontario, Quebec and Alberta) used a common approach to implement six different interventions. This paper describes the protocol to evaluate the processes, outcomes and scalability of these organisational innovations.

METHODS AND ANALYSIS

The evaluation will use a convergent mixed-methods design involving longitudinal (pre and post) analysis of the six interventions. Study participants include vulnerable populations, PHC practices, their clinicians and administrative staff, service providers in other health or social service organisations, intervention staff and members of the LIP teams. Data were collected prior to and 3-6 months after the interventions and included interviews with members of the LIPs, organisational process data, document analysis and tools collecting the cost of components of the intervention. Assessment of impacts on individuals and organisations will rely on surveys and semistructured interviews (and, in some settings, direct observation) of participating patients, providers and PHC practices.

ETHICS AND DISSEMINATION

The IMPACT research programme received initial ethics approval from St Mary's Hospital (Montreal) SMHC #13-30. The interventions received a range of other ethics approvals across the six jurisdictions. Dissemination of the findings should generate a deeper understanding of the ways in which system-level organisational innovations can improve access to PHC for vulnerable populations and new knowledge concerning improvements in PHC delivery in health service utilisation.

Reaching marginalized young women for HIV prevention in Botswana: a pilot social network analysis

Almost one-fifth of Botswana's population is infected with HIV. The Inter-Ministerial National Structural Intervention Trial is a trial to test the impact on HIV rates of a structural intervention that refocuses government structural support programs in favor of young women. Ensuring that the intervention reaches all vulnerable young women in any given community is a challenge. Door-to-door recruitment was inefficient in previous work, so we explored innovative ways to reach this population. We sought to understand the support networks of marginalized young women, and to test the possibility of using social networks to support universal recruitment in this population. Ego-centric and sociometric analyses were used to describe the support networks of marginalized young women. Marginalized young women go to other women and relatives for support, and they communicate face to face rather than using social media. Network maps show how young women were connected to each other. Lessons from the pilot include a better understanding of how to use social networks as a recruitment method, such as the time required and the types of community members that can help. Social networks could help reach other hard-to-reach populations.

Self-management support in primary care is associated with improvement in patient activation

OBJECTIVES

To examine: 1) whether patient characteristics predict perceived self-management support (usefulness of information and collaborative care planning) by primary care providers after six months, and 2) the association between perceived self-management support and patient activation at 6 months METHODS: We conducted a secondary analysis among 120 primary care patients aged 40 and over with a chronic physical condition and comorbid depressive symptoms who participated in a randomized controlled trial of a coaching intervention for depression self-management. Activation was measured at baseline (T0) and 6 months (T1). Self-management support was captured at T1 for physical and mood problems.

RESULTS

The sample of analysis was 120 patients who completed all relevant measures. At T1, the perceived usefulness of information for mood self-management was independently associated with activation. More severe depressive symptoms at T0 predicted lower perceived usefulness of chronic condition self-management information at T1. Lower T0 mental health-related quality of life predicted lower perceived usefulness of mood self-management information at T1.

CONCLUSIONS

Perceived informational support for mood self-management may contribute to increased activation. Patients with more severe mental health symptoms or impairment perceive that they receive less useful self-management information from their care team.

PRACTICE IMPLICATIONS

Care teams should determine whether patients with mood problems need greater self-management support.

Determinants of Overall Satisfaction with Public Clinics in Rural China: Interpersonal Care Quality and Treatment Outcome

The primary health care quality factors determining patient satisfaction will shape patient-centered health reform in China. While rural public clinics performed better than hospitals and private clinics in terms of patient perceived quality of primary care in China, there is little information about which quality care aspects drove patients’ satisfaction. Using a World Health Organization database on 1014 rural public clinic users from eight provinces in China, our multiple linear regression model estimated the association between patient perceived quality aspects, one treatment outcome, and overall primary health care satisfaction. Our results show that treatment outcome was the strongest predictor of overall satisfaction (β = 0.338 (95% CI: 0.284 to 0.392); p < 0.001), followed by two interpersonal care quality aspects, Dignity (being treated respectfully) (β = 0.219 (95% CI: 0.117 to 0.320); p < 0.001) and Communication (clear explanation by the physician) (β = 0.103 (95% CI: 0.003 to 0.203); p = 0.043). Prompt attention (waiting time before seeing the doctor) and Confidentiality (talking privately to the provider) were not correlated with overall satisfaction. The treatment outcome focus, and weak interpersonal primary care aspects, in overall patient satisfaction, pose barriers towards a patient-centered transformation of China’s primary care rural clinics, but support the focus of improving the clinical competency of rural primary care workers.

Can social network analysis help to include marginalised young women in structural support programmes in Botswana? A mixed methods study

Background

In Botswana, one fifth of the adult population is infected with HIV, with young women most at risk. Structural factors such as poverty, poor education, strong gender inequalities and gender violence render many young women unable to act on choices to protect themselves from HIV. A national trial is testing an intervention to assist young women to access government programs for returning to education, and improving livelihoods. Accessing marginalised young women (aged 16–29 and not in education, employment or training) through door-to-door recruitment has proved inefficient. We investigated social networks of young women to see if an approach based on an understanding of these networks could help with recruitment.

Methods

This mixed methods study used social network analysis to identify key young women in four communities (using in-degree centrality), and to describe the types of people that marginalised young women (n = 307) turn to for support (using descriptive statistics and then generalized linear mixed models to examine the support networks of sub-groups of participants). In discussion groups (n = 46 participants), the same young women helped explain results from the network analysis. We also tracked the recruitment method for each participant (door to door, peers, or key community informants).

Results

Although we were not able to identify characteristics of the most central young women in networks, we found that marginalised young women went most often to other women, usually in the same community, and with children, especially if they had children themselves. Rural women were better connected with each other than women in urban areas, though there were isolated young women in all communities. Peer recruitment contributed most in rural areas; door-to-door recruitment contributed most in urban areas.

Conclusions

Since marginalised young women seek support from others like themselves, outreach programs could use networks of women to identify and engage those who most need help from government structural support programs. Methods that rely on social networks alone may be insufficient, and so a combination of approaches, including, for instance, peers, door-to-door recruitment, and key community informants, should be explored as a strategy for reaching marginalised young women for supportive interventions.

Electronic supplementary material

The online version of this article (10.1186/s12939-019-0911-8) contains supplementary material, which is available to authorized users.

A systematic mixed studies review on Organizational Participatory Research: towards operational guidance

BACKGROUND

Organizational Participatory Research (OPR) seeks organizational learning and/or practice improvement. Previous systematic literature reviews described some OPR processes and outcomes, but the link between these processes and outcomes is unknown. We sought to identify and sequence the key processes of OPR taking place with and within healthcare organizations and the main outcomes to which they contribute, and to define ideal-types of OPR.

METHODS

This article reports a participatory systematic mixed studies review with qualitative synthesis A specialized health librarian searched MEDLINE, CINAHL, Embase Classic + Embase, PsycINFO, the Cochrane Library, Social Work Abstracts and Business Source Complete, together with grey literature data bases were searched from inception to November 29, 2012. This search was updated using forward citation tracking up to June 2014. Reporting quality was appraised and unclear articles were excluded. Included studies clearly reported OPR where the main research related decisions were co-constructed among the academic and healthcare organization partners. Included studies were distilled into summaries of their OPR processes and outcomes, which were subsequently analysed using deductive and inductive thematic analysis. All summaries were analysed; that is, data analysis continued beyond saturation.

RESULTS

Eighty-three studies were included from the 8873 records retrieved. Eight key OPR processes were identified. Four follow the phases of research: 1) form a work group and hold meetings, 2) collectively determine research objectives, 3) collectively analyse data, and 4) collectively interpret results and decide how to use them. Four are present throughout OPR: 1) communication, 2) relationships; 3) commitment; 4) collective reflection. These processes contribute to extra benefits at the individual and organizational levels. Four ideal-types of OPR were defined. Basic OPR consists of OPR processes leading to achieving the study objectives. This ideal-type and may be combined with any of the following three ideal-types: OPR resulting in random additional benefits for the individuals or organization involved, OPR spreading to other sectors of the organization and beyond, or OPR leading to subsequent initiatives. These results are illustrated with a novel conceptual model.

CONCLUSION

The model provides operational guidance to help OPR stakeholders collaboratively address organizational issues and achieve desired outcomes and more.

REVIEW REGISTRATION

As per PROSPERO inclusion criteria, this review is not registered.

Snapshot of the primary care waiting room: Informing practice redesign to align with the Patient's Medical Home model

OBJECTIVE

To describe the demographic characteristics, health, and health care experiences of adult patients in primary care waiting rooms in Quebec, and to determine which pillars of the Patient's Medical Home (PMH) are a priority to align primary care practices with the PMH model.

DESIGN

Baseline survey of a prospective cohort study using self-administered on-site and mailed questionnaires.

SETTING

Twelve primary care clinics within the geographic boundaries of 4 local health care networks in metropolitan, urban, rural, and remote settings in Quebec.

PARTICIPANTS

A total of 1029 adult patients aged between 25 and 75 who were selected during a 1-week period in the 12 primary care clinics; 789 returned questionnaires.

MAIN OUTCOME MEASURES

Patients' health profiles, health behaviour patterns, reasons for the visit, and health care experiences.

RESULTS

In this 2010 snapshot, 66.8% of patients waited longer than 2 weeks for their appointment, 71.0% of visits were for routine or follow-up care, and longer wait times and patient multimorbidity correlated with more reasons for the visit. After the visit, most patients reported being able to express their most important needs and that the doctor listened well; however, only 28.1% reported that the doctor had explored whether the recommendations would be realistic for them, and only 18.0% indicated that the doctor had explored the personal or family dimensions that affected their health. Among all patients, 56.9% reported having at least 3 chronic conditions (multimorbidity), and 30.3% reported having high or moderate levels of psychological distress. When describing their financial status, 30.7% of patients indicated it was "poor to squeezed or tight." Slightly more than half of patients did not have complementary private health insurance to cover costs of psychological services.

CONCLUSION

In this study, the 4 priority pillars for practices to align with the PMH were timely access, team-based care, comprehensive care, and a patient-centred approach. Widespread implementation of advanced access is an urgent priority in light of persisting difficulties in timely access. Team-based and comprehensive care are needed to address the high prevalence of multimorbidity and psychological distress and to support health behaviour change. Finally, the patient-centred approach needs to underpin every care encounter.

Stakeholder Views on Solutions to Improve Health System Performance

Context

Significant reforms are needed to improve healthcare system performance in Quebec. Even though the characteristics of high-performing healthcare systems are well-known, Quebec's reforms have not succeeded in implementing many critical elements. Converging evidence from political science models suggests stakeholders' preferences are central in determining policy content, adoption, and implementation.

Objective

To analyze whether doctors', nurses', pharmacists' and health administrators' preferences could explain the observed inability to implement known characteristics of high-performing healthcare systems.

Design

A questionnaire on various propositions identified in the scientific literature was sent to 2,491 potential respondents.

Results

Overall response rate was 37%. There was considerable consensus on identified solutions to improve the healthcare system. Resistance was observed in two major areas: information systems and changes directly affecting doctors' practice. The groups' positions cannot explain the inability to implement important characteristics of high-performing systems. The findings raise new questions on the actual sources of resistance.

Healthcare reforms, inertia polarization and group influence

Healthcare systems performance is the focus of intense policy and media attention in most countries. Quebec (Canada) is no exception, where successive governments have struggled for decades with apparently intractable problems in care accessibility overall, poor performance, and rising costs. This article explores the underlying causes of the disconnection between the high salience of healthcare system dysfunctions in both media and policy debates and the lack of policy change likely to remedy those dysfunctions. Academically, public policies' evolution is usually conceptualized as the product of complex, long-term interactions among diverse groups with specific power sources and preferences. In this context, we wanted to examine empirically whether divergences in stakeholders' views concerning various healthcare reform options could explain why certain policy changes are not implemented despite consensus on their programmatic coherence. The research design was an exploratory sequential design. Data were analyzed narratively as well as graphically using a method derived from social network analysis and graph theory. Results showed striking intergroup convergence around a programmatically sound policy package centred on the general objective of strengthening primary care delivery capacities. Those results, interpreted in light of political science elitist perspectives on the policy process, suggest that the incapacity to reform the system might be explained by one or two groups' having a de facto veto in policy-making.

The influence of patient-clinician ethnocultural and language concordance on continuity and quality of care: a cross-sectional analysis

BACKGROUND

Concordance refers to shared characteristics between a clinician and patient, such as ethnicity or language. The purpose of this study was to examine whether patient-clinician concordance is associated with patient-reported continuity of care (relational, informational and management) and patient-reported impacts of care (quality and empowerment).

METHODS

This is a secondary analysis of cross-sectional patient surveys that were administered across British Columbia, Manitoba and Quebec using random digit dialling. Participants were adults who spoke English, French, Mandarin, Cantonese or Punjabi and who had visited a primary care clinician in the previous 12 months (n = 3156). Patients self-identified as being of European, Chinese, South Asian and Indigenous descent. Outcome measures included patients' perceptions of continuity, quality and empowerment. Adjusted logistic regression models and odds ratio were generated.

RESULTS

More than 64% of non-Indigenous respondents reported ethnocultural concordance. Ethnocultural concordance was associated with higher odds of relational and management continuity. This same pattern held when there was both ethnocultural and language concordance. No association was found between language concordance and any outcome measure. Chinese participants reported lower quality (odds ratio [OR] 0.24, 95% confidence interval [CI] 0.12-0.48), as did South Asian participants (OR 0.17, 95% CI 0.09-0.31) than did participants of European descent.

INTERPRETATION

Higher relational and management continuity is more likely with the presence of patient-clinician ethnocultural and language concordance. Lower continuity and quality reported by Chinese and South Asian particpants could indicate important health care disparities.

Barriers to accessing primary health care: comparing Australian experiences internationally

Most highly developed economies have embarked on a process of primary health care (PHC) transformation. To provide evidence on how nations vary in terms of accessing PHC, the aim of this study is to describe the extent to which barriers to access were experienced by adults in Australia compared with other countries. Communities participating in an international research project on PHC access interventions were engaged to prioritise questions from the 2013 Commonwealth Fund International Health Policy Survey within a framework that conceptualises access across dimensions of approachability, acceptability, availability, affordability and appropriateness. Logistic regression models, with barriers to access as outcomes, found measures of availability to be a problematic dimension in Australia; 27% of adults experienced difficulties with out-of-hours access, which was higher than 5 of 10 comparator countries. Although less prevalent, affordability was also perceived as a substantial barrier; 16% of Australians said they had forgone health care due to cost in the previous year. After adjusting for age and health status, this barrier was more common in Australia than 7 of 10 countries. Findings of this integrated assessment of barriers to access offer insights for policymakers and researchers on Australia's international performance in this crucial PHC domain.

Decisional needs assessment of patients with complex care needs in primary care: a participatory systematic mixed studies review protocol

INTRODUCTION

Patients with complex care needs (PCCNs) often suffer from combinations of multiple chronic conditions, mental health problems, drug interactions and social vulnerability, which can lead to healthcare services overuse, underuse or misuse. Typically, PCCNs face interactional issues and unmet decisional needs regarding possible options in a cascade of interrelated decisions involving different stakeholders (themselves, their families, their caregivers, their healthcare practitioners). Gaps in knowledge, values clarification and social support in situations where options need to be deliberated hamper effective decision support interventions. This review aims to (1) assess decisional needs of PCCNs from the perspective of stakeholders, (2) build a taxonomy of these decisional needs and (3) prioritise decisional needs with knowledge users (clinicians, patients and managers).

METHODS AND ANALYSIS

This review will be based on the interprofessional shared decision making (IP-SDM) model and the Ottawa Decision Support Framework. Applying a participatory research approach, we will identify potentially relevant studies through a comprehensive literature search; select relevant ones using eligibility criteria inspired from our previous scoping review on PCCNs; appraise quality using the Mixed Methods Appraisal Tool; conduct a three-step synthesis (sequential exploratory mixed methods design) to build taxonomy of key decisional needs; and integrate these results with those of a parallel PCCNs' qualitative decisional need assessment (semistructured interviews and focus group with stakeholders).

ETHICS AND DISSEMINATION

This systematic review, together with the qualitative study (approved by the Centre Intégré Universitaire de Santé et Service Sociaux du Saguenay-Lac-Saint-Jean ethical committee), will produce a working taxonomy of key decisional needs (ontological contribution), to inform the subsequent user-centred design of a support tool for addressing PCCNs' decisional needs (practical contribution). We will adapt the IP-SDM model, normally dealing with a single decision, for PCCNs who experience cascade of decisions involving different stakeholders (theoretical contribution). Knowledge users will facilitate dissemination of the results in the Canadian primary care network.

PROSPERO REGISTRATION NUMBER

CRD42015020558.

Organizational participatory research: a systematic mixed studies review exposing its extra benefits and the key factors associated with them

BACKGROUND

In health, organizational participatory research (OPR) refers to health organization members participating in research decisions, with university researchers, throughout a study. This non-academic partner contribution to the research may take the form of consultation or co-construction. A drawback of OPR is that it requires more time from all those involved, compared to non-participatory research approaches; thus, understanding the added value of OPR, if any, is important. Thus, we sought to assess whether the OPR approach leads to benefits beyond what could be achieved through traditional research.

METHODS

We identified, selected, and appraised OPR health literature, and at each stage, two team members independently reviewed and coded the literature. We used quantitative content analysis to transform textual data into reliable numerical codes and conducted a logistic regression to test the hypothesis that a co-construction type OPR study yields extra benefits with a greater likelihood than consultation-type OPR studies.

RESULTS

From 8873 abstracts and 992 full text papers, we distilled a sample of 107 OPR studies. We found no difference between the type of organization members' participation and the likelihood of exhibiting an extra benefit. However, the likelihood of an OPR study exhibiting at least one extra benefit is quadrupled when the impetus for the study comes from the organization, rather than the university researcher(s), or the organization and the university researcher(s) together (OR = 4.11, CI = 1.12-14.01). We also defined five types of extra benefits.

CONCLUSIONS

This review describes the types of extra benefits OPR can yield and suggests these benefits may occur if the organization initiates the OPR. Further, this review exposes a need for OPR authors to more clearly describe the type of non-academic partner participation in key research decisions throughout the study. Detailed descriptions will benefit others conducting OPR and allow for a re-examination of the relationship between participation and extra benefits in future reviews.

Comparison of patient perceived primary care quality in public clinics, public hospitals and private clinics in rural China

Background

In rural China, patients have free choice of health facilities for outpatient services. Comparison studies exploring the attributes of different health facilities can help identify optimal primary care service models. Using a representative sample of Chinese provinces, this study aimed to compare patients’ rating of three primary care service models used by rural residents (public clinics, public hospitals and private clinics) on a range of health care attributes related to responsiveness.

Methods

This was a secondary analysis using the household survey data from World Health Organization (WHO) Study on global AGEing and adult health (SAGE). Using a multistage cluster sampling strategy, eight provinces were selected and finally 3435 overall respondents reporting they had visited public clinics, public hospitals or private clinics during the last year, were included in our analysis. Five items were used to measure patient perceived quality in five domains including prompt attention, communication and autonomy, dignity and confidentiality. ANOVA and Turkey’s post hoc tests were used to conduct comparative analysis of five domains. Separate multivariate linear regression models were estimated to examine the association of primary care service models with each domain after controlling for patient characteristics.

Results

The distribution of last health facilities visited was: 29.5% public clinics; 31.2% public hospitals and; 39.3% private clinics. Public clinics perform best in all five domains: prompt attention (4.15), dignity (4.17), communication (4.07), autonomy (4.05) and confidentiality (4.02). Public hospitals perform better than private clinics in dignity (4.03 vs 3.94), communication (3.97 vs 3.82), autonomy (3.92 vs 3.74) and confidentiality (3.94 vs 3.73), but equivalently in prompt attention (3.92 vs 3.93). Rural residents who are older, wealthier, and with higher self-rated health status have significantly higher patient perceived quality of care in all domains.

Conclusions

Rural public clinics, which share many characteristics with the optimal primary care delivery model, should be strongly strengthened to respond to patients’ needs. Better doctor-patient interaction training would improve respect, confidentiality, autonomy and, most importantly, health care quality for rural patients.

Self-reported versus health administrative data: implications for assessing chronic illness burden in populations. A cross-sectional study

BACKGROUND

Various data sources may be used to document the presence of chronic medical conditions. This study examined the agreement between self-reported and health administrative data.

METHODS

A randomly selected cohort of participants aged 25-75 years recruited by telephone from the general population of Quebec reported on the presence of 1 or more chronic conditions from a candidate list of 12 conditions: diabetes, hypertension, thyroid disorder, any cardiac disease, cancer diagnosis in the previous 5 years (including melanoma but excluding other skin cancers), asthma, osteoarthritis, rheumatoid arthritis or lupus, osteoporosis, chronic obstructive pulmonary disease, intestinal disease and hypercholesterolemia. We also used health administrative data from Quebec's universal health insurance provider to identify participants' chronic conditions. Unique identifiers allowed linkage of both data sources to the individual participant. The frequencies of the 12 conditions and the prevalence of multimorbidity (≥ 2, ≥ 3 and ≥ 4 conditions) were analyzed for each data source.

RESULTS

We analyzed data for 1177 participants (mean age 53 [standard deviation 12.4] yr; 684 women [58.1%]). We found low (but varied) agreement between the 2 data sources, with the poorest agreement for hypercholesterolemia (κ = 0.04 [95% confidence interval (CI) 0.01 to 0.07]) and the best for diabetes (κ = 0.82 [95% CI 0.76 to 0.88]). Prevalence estimates of multimorbidity obtained with health administrative data were lower than those obtained with self-reported data regardless of the operational definition used. Most participants with multimorbidity were identified by self-report.

INTERPRETATION

We argue for the use of self-reported chronic conditions in the study of multimorbidity, as health administrative data based on the billing system in Quebec seem to underestimate the prevalence of many chronic conditions, which results in biased estimates of multimorbidity.

[Financing, organization, costs and services performance of the Argentinean health sub-systems.]

Objective:

To analyze the relationship between health system financing and services organization models with costs and health services performance in each of Rosario's health sub-systems.

Materials and methods:

The financing and organization models were characterized using secondary data. Costs were calculated using the WHO/SHA methodology. Healthcare quality was measured by a household survey (n=822).

Results:

Public subsystem:Vertically integrated funding and primary healthcare as a leading strategy to provide services produced low costs and individual-oriented healthcare but with weak accessibility conditions and comprehensiveness. Private subsystem: Contractual integration and weak regulatory and coordination mechanisms produced effects opposed to those of the public sub-system. Social security: Contractual integration and strong regulatory and coordination mechanisms contributed to intermediate costs and overall high performance.

Conclusion:

Each subsystem financing and services organization model had a strong and heterogeneous influence on costs and health services performance.